Qualchoice.magellanrx.com

Magellan Rx Management

Provider Manual

Proprietary & Confidential

? 2014?2024 All rights reserved. Magellan Rx Management LLC, a Prime Therapeutics company

Table of Contents

1.0

1.1

2.0

2.1

2.2

2.3

2.4

2.5

2.6

3.0

3.1

3.2

4.0

4.1

4.2

4.3

5.0

5.1

5.2

5.3

6.0

6.1

6.2

7.0

7.1

7.2

8.0

8.1

8.2

8.3

8.4

8.5

8.6

8.7

8.8

8.9

8.10

Page 2

Introduction ..........................................................................................................................6

MRx Pharmacy Program .............................................................................................................. 6

Pharmacy Relations ...............................................................................................................7

Enrolling as an Approved Pharmacy ............................................................................................ 7

Credentialing and Quality Management ................................................................................... 22

Member Complaints .................................................................................................................. 25

Medication Error Reporting....................................................................................................... 25

Pharmacy Dispute Process ........................................................................................................ 25

Pharmacy Suspension Process .................................................................................................. 26

Billing Information ...............................................................................................................28

Claim Formats and Plan ¨C Specific Values ................................................................................. 28

Magellan Rx Management (MRx) Website Pharmacy Portal .................................................... 28

Call Center Services ..............................................................................................................29

Pharmacy Support Center ......................................................................................................... 29

Clinical Support Call Center ....................................................................................................... 29

Web Support Call Center ........................................................................................................... 29

Program Setup .....................................................................................................................30

Claim Format ............................................................................................................................. 30

Point-of-Sale ¨C NCPDP Version D.0 ........................................................................................... 30

Paper Claims .............................................................................................................................. 33

Service Support....................................................................................................................35

Online Certification ................................................................................................................... 35

Solving Technical Problems ....................................................................................................... 35

Online Claims Processing Edits .............................................................................................36

Paid, Denied, and Rejected Responses ..................................................................................... 36

Duplicate Response ................................................................................................................... 36

Program Specifications .........................................................................................................37

Timely Filing Limits .................................................................................................................... 37

Mandatory Generic Requirements ............................................................................................ 37

Dispensing Limits/Claim Restrictions ........................................................................................ 37

Provider Reimbursement .......................................................................................................... 38

Plan Co-Pays .............................................................................................................................. 39

Prior Authorizations .................................................................................................................. 39

ProDUR Drug Utilization Review ............................................................................................... 41

Retro DUR .................................................................................................................................. 44

Special Participant Conditions ................................................................................................... 46

Compound Claims...................................................................................................................... 46

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Magellan Rx Management Provider Manual

8.11 Partial Fills ................................................................................................................................. 47

9.0

Coordination of Benefits ......................................................................................................49

9.1

COB General Instructions .......................................................................................................... 49

10.0 Appendix A: Plan D.0 Payer Specification ..............................................................................53

11.0 Appendix B: Point-of-Sale Reject Codes and Messages ..........................................................54

11.1 Version D.0 Reject Codes for Telecommunication Standard .................................................... 54

12.0 Appendix C: State Regulatory Requirements .........................................................................65

12.1 Medicare Part D......................................................................................................................... 65

12.2 Alabama ..................................................................................................................................... 81

12.3 Alaska......................................................................................................................................... 83

12.4 Arizona ....................................................................................................................................... 85

12.5 Arkansas .................................................................................................................................... 87

12.6 California ................................................................................................................................... 88

12.7 Colorado .................................................................................................................................... 97

12.8 Connecticut.............................................................................................................................. 102

12.9 Delaware.................................................................................................................................. 105

12.10 District of Columbia ................................................................................................................. 106

12.11 Florida ...................................................................................................................................... 107

12.12 Georgia .................................................................................................................................... 112

12.13 Hawaii ...................................................................................................................................... 114

12.14 Idaho ........................................................................................................................................ 115

12.15 Illinois....................................................................................................................................... 117

12.16 Indiana ..................................................................................................................................... 120

12.17 Iowa ......................................................................................................................................... 124

12.18 Kansas ...................................................................................................................................... 126

12.19 Kentucky .................................................................................................................................. 127

12.20 Louisiana .................................................................................................................................. 130

12.21 Maine....................................................................................................................................... 131

12.22 Maryland ................................................................................................................................. 133

12.23 Massachusetts ......................................................................................................................... 136

12.24 Michigan .................................................................................................................................. 138

12.25 Minnesota................................................................................................................................ 142

12.26 Mississippi ............................................................................................................................... 145

12.27 Missouri ................................................................................................................................... 147

12.28 Montana .................................................................................................................................. 152

12.29 Nebraska .................................................................................................................................. 154

12.30 Nevada ..................................................................................................................................... 161

12.31 New Hampshire ....................................................................................................................... 163

12.32 New Jersey............................................................................................................................... 165

12.33 New Mexico ............................................................................................................................. 172

Magellan Rx Management Provider Manual

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12.34 New York ................................................................................................................................. 175

12.35 North Carolina ......................................................................................................................... 188

12.36 North Dakota ........................................................................................................................... 191

12.37 Ohio ......................................................................................................................................... 192

12.38 Oklahoma ................................................................................................................................ 196

12.39 Oregon ..................................................................................................................................... 197

12.40 Pennsylvania ............................................................................................................................ 198

12.41 Rhode Island ............................................................................................................................ 202

12.42 South Carolina ......................................................................................................................... 204

12.43 South Dakota ........................................................................................................................... 205

12.44 Tennessee ................................................................................................................................ 207

12.45 Texas ........................................................................................................................................ 208

12.46 Utah ......................................................................................................................................... 213

12.47 Vermont................................................................................................................................... 214

12.48 Virginia ..................................................................................................................................... 217

12.49 Washington ............................................................................................................................. 223

12.50 West Virginia ........................................................................................................................... 227

12.51 Wisconsin ................................................................................................................................ 232

12.52 Wyoming ................................................................................................................................. 238

13.0 Appendix D: Magellan Rx Management (MRx) Account ....................................................... 239

13.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form ................................. 239

13.2 Website Pharmacy Portal ........................................................................................................ 240

13.3 Pharmacy Support Center ....................................................................................................... 240

13.4 Clinical Support Center ............................................................................................................ 240

13.5 Web Support ........................................................................................................................... 241

13.6 Universal Claim Form .............................................................................................................. 241

13.7 Request a Contract for Extended Days¡¯ Supply Participation ................................................. 241

13.8 Pharmacy Contracts for Provider Reimbursement Rates........................................................ 241

13.9 Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of

Edits ......................................................................................................................................... 241

13.10 Payer Specification Document ................................................................................................ 241

13.11 Contact Information ................................................................................................................ 242

14.0 Appendix E: Community Care Plan (CCP) ............................................................................. 243

14.1 Pharmacy Application and Agreement and Pharmacy Disclosure Form ................................. 243

14.2 Website Pharmacy Portal ........................................................................................................ 244

14.3 Pharmacy Support Center ....................................................................................................... 244

14.4 Clinical Support Center ............................................................................................................ 244

14.5 Web Support ........................................................................................................................... 244

14.6 Universal Claim Form .............................................................................................................. 244

14.7 Request a Contract for Extended Days¡¯ Supply Participation ................................................. 244

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Magellan Rx Management Provider Manual

14.8

14.9

Pharmacy Contracts for Provider Reimbursement Rates........................................................ 245

Complete List of PA Criteria, Step Therapy Requirements, Quantity Limits, and Duration of

Edits ......................................................................................................................................... 245

14.10 Payer Specification Document ................................................................................................ 245

14.11 Contact Information ................................................................................................................ 245

15.0 Appendix F: Medicare Part D Network ................................................................................ 247

15.1 Services .................................................................................................................................... 247

15.2 Claim Processing ...................................................................................................................... 247

15.3 Compliance with Legal Regulations ......................................................................................... 248

15.4 Pharmacy Help Desk ................................................................................................................ 249

15.5 Eligibility Validation ................................................................................................................. 249

15.6 Low Income Subsidy (LIS) Change in Status ............................................................................ 249

15.7 Disaster Declaration ................................................................................................................ 250

15.8 Best Available Evidence (BAE) ................................................................................................. 250

15.9 Medicare Part D Claims Adjustment ....................................................................................... 251

15.10 General Medicare Part D Submission Requirements for COB................................................. 251

15.11 Emergency Overrides .............................................................................................................. 252

15.12 Marketing ................................................................................................................................ 252

15.13 Tamper Resistant Pads ............................................................................................................ 252

15.14 Medication Error Reporting..................................................................................................... 252

15.15 Formulary Transition Fill Process ............................................................................................ 252

15.16 Reject Messaging for Part B versus Part D Drug Coverage Determination ............................. 254

15.17 End Stage Renal Disease (ESRD) Custom Reject Messaging .................................................... 254

15.18 Long Term Care Pharmacy Providers ...................................................................................... 255

15.19 Maximum Allowable Cost (MAC) ............................................................................................ 257

16.0 Appendix G: Discrepancy Code List ..................................................................................... 259

17.0 Definitions ......................................................................................................................... 267

Magellan Rx Management Provider Manual

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